Breast lumps can be very common and occur in a majority of women in their lifetime. Most lumps will not be a breast cancer, but checking with a physician is important to be sure. Figuring out what a lump is depends on your age and symptoms. For example, a young woman who is nursing and has developed a painful lump often has a build-up of milk (a lactating adenoma) or if redness is also present, an abscess or infection could be present. Pre- and perimenopausal women can often develop benign fluid-filled lumps, or cysts that are non-cancerous but can sometimes be painful. On the other hand, if a postmenopausal woman develops a painless lump, the presence of cancer is more likely.
Typically, the diagnostic work-up for a lump looks like this:
For women <30 years old: Ultrasound
For women 30+: Ultrasound and Mammogram;
If redness of the skin is present, start antibiotics (I typically choose Bactrim unless there is an allergy to sulfas) while waiting for diagnostic imaging.
Again, a new lump in a young woman is often non-cancerous, but a new lump in a postmenopausal woman should not be ignored as there is a higher likelihood that this lump is a cancer. While the average age of breast cancer in the United States is 62, approximately 1.5% percent of women under the age of 40 will develop a breast cancer.
The differential diagnosis of the breast lump includes:
1. Breast cyst
2. Fibroglandular breast tissue (another term normal, lumpy breast tissue)
6. Other benign disorder including complex cysts, papilloma, phyllodes tumor, granulomatous mastitis, diabetic mastopathy, fat necrosis and hematomas
Simple cysts are easy to diagnose on ultrasound as smooth round lesions that are black on the inside, indicating fluid. They do not require intervention unless they are causing discomfort or bothersome change in breast shape. Complex cysts are slightly more challenging and often radiologists will prefer to recheck these with ultrasound 6 months later and less frequently biopsy is recommended. Very infrequently, complex cysts may have growth within them that indicates intraductal malignancy, but more likely these are cysts with debris inside of them.
Often, breast lumps are from fibroglandular breast tissue. This is normal breast tissue that can often swell and become tender with menstrual cycles. It typically feels rubbery, is often symmetric to the other side, and is not fixed to the tissue. Reassurance of normal findings and a three-month follow-up visit is a good idea. Very rarely, what appears to be normal tissue can be hiding a small cancer, often this is a lobular cancer, so follow-up is important. If you feel the lump is definitely new and not improving, then sometimes needle biopsy is necessary to confirm there is no occult malignancy.
Fibroadenomas are also usually easy to identify on ultrasound as smooth solid lesions. They are often followed with ultrasound and sometimes they are also biopsied to confirm benign finding. These lesions also don’t require intervention unless they are enlarging, painful, or causing a change in the shape of the breast. Cryoablation, or freezing the breast tissue, is also an option for management of fibroadenomas.
Abscesses should first undergo needle drainage, not open drainage, and antibiotics should be started. Typically, we send the fluid for culture to make sure the correct antibiotics are being given, and occasionally a repeat drainage is needed. For more complex cases, especially those with delayed diagnosis and treatment, surgical drainage may be needed after needle drainage has been attempted.
Even with regular screening and mammography, breast cancer sometimes still presents itself as a mass. This occurs in women with very dense breast tissue such that cancer cannot be detected with mammography alone, in young women who are not getting screened routinely because they are too young to typically necessitate mammography, in settings of lobular breast cancer which is sometimes harder to find on any imaging, in women who have not been doing routine breast cancer screening, or with very aggressive, fast growing tumors.
If you are concerned about a breast mass, be sure to be evaluated by your physician or other breast specialist. If the mass is not going away and you’re still concerned about it, be sure to have thorough diagnosis and evaluation. This includes clinical breast exam, ultrasound with or without mammogram, and needle biopsy if necessary.